Leslie Boydell Institute of Public Health

1. Health inequalities in Ireland: implications for research and policy Leslie Boydell Institute of Public Health Domains and dimensions of health systems research 31st August 2007 www.publichealth.ie

2. Of all forms of inequalities, inequalities in health are the most inhumane Martin Luther King

3. Three distinguishing features, when combined, turn mere variations or difference in health into a social inequity in health. They are systematic, socially produced (and therefore modifiable) and unfair Dahlgren and Whitehead

4. What I will cover • Inequalities in health in Ireland • The policy context • Research into inequalities in health in Ireland • International inequalities research • Getting research evidence into policy • Future needs for inequalities research in Ireland and contribution of the health system

5. Inequalities in health in Ireland The policy context Research into inequalities in health in Ireland International inequalities research Getting research evidence into policy Future needs for inequalities research in Ireland and contribution of the health system What I will cover

6. In Ireland, north and south: • All cause mortality rate in lowest occupational classes is 100-200% higher For circulatory disease, it is 120% higher • For cancers, it is 100% higher • For respiratory disease, it is >200% higher • For injuries and poisoning, it is >150% higher

7. In Ireland: • Mortality rate from transport accidents is 354% higher • Hospitalisation for mental illness among unskilled workers is 6x higher

8. 37% of women with medical cards smoke during pregnancy vs 12% of mothers without • 27% of babies born to unemployed mothers were breastfed vs 67% of babies born to higher professional women

9. In Northern Ireland: • Children from disadvantaged backgrounds are 2x as likely to die before their 15th birthday • The average suicide rate in economically deprived areas is 2x that of non-deprived areas

10. Inequalities in health in Ireland The policy context Research into inequalities in health in Ireland International inequalities research Getting research evidence into policy Future needs for inequalities research in Ireland and contribution of the health system What I will cover

11. Policy context

12. Policy context • National Report for Ireland on Strategies for Social Protection and Social Inclusion 2006-2008 • National Action Plan for Social Inclusion 2007-2016

14. Inequalities in health in Ireland The policy context Research into inequalities in health in Ireland International inequalities research Getting research evidence into policy Future needs for inequalities research in Ireland and contribution of the health system What I will cover

15. Research into health inequalities in Ireland • Descriptive of inequalities and the social gradient • Health of specific groups • Service access and utilisation • Evaluations of interventions • Methods of measurement • Methods of working • Lifecourse

16. Gaps • User perspective or research into lived experience • Intervention research • Analysis of mainstream data sources and surveys limited by data collected • Methods

17. Inequalities in health in Ireland The policy context Research into inequalities in health in Ireland International inequalities research Getting research evidence into policy Future needs for inequalities research in Ireland and contribution of the health system What I will cover

18. Global Commission on the Social Determinants of Health Purpose: To achieve policy change by learning from what we know about the social determinants of health www.who.int/social_determinants/resources/en

19. Activities: • Mechanisms by which social determinants generate health inequalities • Relationships between the determinants of health • Policy entry points

20. Distinctions • Structural determinants of health (eg income and education) • Intermediate determinants (eg living and working conditions, population behaviour and food availability)

21. “To eradicate inequalities in health, we need to eliminate the social determinants of health inequalities”

22. Limitations of evidence base • Studies explaining what can be done to reduce health inequalities • Systematic studies of policy effects on inequity • Difference between the determinants of health and the determinants of health inequalities often confused • Health of populations and the health of individuals often elided • Links between proximal, intermediate and distal determinants of health poorly conceptualised

23. “Further research is needed but enough is presently known for effective action” Dahlgren and Whitehead

24. Inequalities in health in Ireland The policy context Research into inequalities in health in Ireland International inequalities research Getting research evidence into policy Future needs for inequalities research in Ireland and contribution of the health system What I will cover

25. Evidence Experience Judgement Resources Values Policy-making

26. Policy-making • Rarely an event • Timing of decisions determined by political considerations • Decisions tend to be driven by underlying beliefs • Social climate will determine what is popular or acceptable • Competing interests will influence what decisions are made

27. Policy-making Scientific plausibility Political acceptability What is practically implementable

28. What we need to understand • Policy entry points • Place of evidence in policy making • How to achieve best fit with dominant political vision and desired outcomes • Importance of local infrastructure for implementation • Political nature of policy making • Prepared advocate

29. Inequalities in health in Ireland The policy context Research into inequalities in health in Ireland International inequalities research Getting research evidence into policy Future needs for inequalities research in Ireland and contribution of the health system What I will cover

30. So what is needed in Ireland? • Research into what works • Strong advocacy • To maximise public involvement • Intervene with children • To tackle the social determinants of health inequalities • Policies which have greater beneficial effects on disadvantaged groups

31. So what is needed in Ireland? • To address the gradient • Work on knowledge transfer • Research into the effects of policies on the unequal distribution of the major factors which influence health

32. As a research community we need to: • Increase awareness across government and academic disciplines of the centrality of non-health policies and interventions for improving health and tackling health inequalities

33. As a research community we need to: • Ensure that policy evaluations include measures of health determinants, risk factors and health status • Ensure that evaluation of policies and interventions include effects on subgroups

34. As a research community we need to: • Ensure that policy evaluations include measures of health determinants, risk factors and health status • Ensure that evaluation of policies and interventions include effects on subgroups

35. As a research community we need to: • Interdisciplinary research and a variety of methods • Research designs and evaluation strategies that capture the effects of policies on health determinants and outcomes • More research funding on interventions to reduce inequalities

36. As a research community we need to: • Consider the relationships between the different dimensions of inequalities and how they interact • Study differential responses to similar interventions between different groups • Ensure an inequalities dimension included in topic based research

37. As a research community we need to: • Make tackling health inequalities a priority • Develop strategy • Gather information • Integrate action across all health programmes

38. What can the health services do? • Pursue community and public involvement work in partnership with other sectors • Improve access for and differentially address the needs of disadvantaged and marginalised groups

39. Inequalities in health in Ireland The policy context Research into inequalities in health in Ireland International inequalities research Getting research evidence into policy Future needs for inequalities research in Ireland and contribution of the health system What I will cover